Subject ID : Subject ID

Study Event ID

Group: Common

Site number Must be an integer.Value must be lower than 100

Visit Date Must be a valid date. Correct format is: yyyy-mm-dd

Group: Demographics

Date of Birth Must be a valid date. Correct format is: yyyy-mm-dd

Sex Male M Female F

Race Caucasian CAUCASIAN Black BLACK Asian ASIAN Other OTHER

Group: Smoking History

Is the subject a smoker

Number of cigarettes per day Less Than 10 cigarettes per day LT10 10 to 20 cigarettes per day 10TO20 Greater Than 20 cigarettes per day GT20

Group: Drinking history

Number of alcoholic drinks per day Less Than 1 drink per day LT1 1 to 2 drinks per day 1TO2 Greater Than 2 drinks per day GT2

Group: Physical examination: Baseline

Height (cm) The height value should be below 220 cm

Weight (kg) The weight value should be below 150 kg

Systolic BP (mm Hg) The value should be below 180

Diastolic BP (mm Hg) The value should be below 120

Does the subject feel dizzy when standing up from a sitting position No 0 Yes 1

Group: Complaints related to smoking

Breathing No 0 Yes 1

Coughing No 0 Yes 1

Heart No 0 Yes 1

No. of illness days last year Must be an integer.Value must be lower than 1000

Number of bronchitis cases during the last year Must be an integer.Value must be lower than 100

Number of pneumonia cases last year Must be an integer.Value must be lower than 100